USLME surgery

A 22-year-old woman presents with a painful fluctuant mass in the midline between the gluteal folds. She denies pain on rectal examination. Which of the following is the most likely diagnosis?

A 62-year-old man has been diagnosed by endoscopic biopsy as having a sigmoid colon cancer. He is otherwise healthy and presents to your office for preoperative consultation. He asks a number of questions regarding removal of a portion of his colon. Which of the following is most likely to occur after a colon resection?

A 40-year-old female is brought to the emergency department following a motor vehicle accident in which she was the front seat passenger. She reports hitting her head against the windshield and hurting her right leg. She appears completely alert and oriented. Glasgow Coma Scale =15/15. Her pupils are equal and reactive to light. There is a bruise over the right forehead, but no tenderness is present on palpation of the cranial bones. Examination of the right leg reveals a hematoma over the thigh. Knee extension on the right is markedly reduced when compared to the left. Sensory examination reveals decreased sensory perception to both sharp and dull stimuli over the medial side of the right lower thigh and leg. All other dermatomes are intact. What nerve injury is most likely present in this patient?

A 28-year-old woman who is 15 weeks pregnant has new onset of nausea, vomiting, and right sided abdominal pain. She has been free of nausea since early in her first trimester. The pain has become worse over the past 6 hours. Which of the following is the most common non-obstetric surgical disease of the abdomen during pregnancy?

A 30-year-old female patient who presents with diarrhea and abdominal discomfort is found at colonoscopy to have colitis confined to the transverse and descending colon. A biopsy is performed. Which of the following is a finding consistent with this patient’s diagnosis?

A 62-year-old man presents with a 3-month history of an enlarged lymph node in the left neck. He is a long-time smoker of cigarettes and denies fevers, night sweats, fatigue, or cough. On physical examination there is a 1.5 cm hard, fixed mass below the angle of the mandible in the left neck. Which of the following is the most likely cause of an enlarged lymph node in the neck?

A 53-year-old male is brought to the emergency room after a high-speed motor vehicle accident. He was an unrestrained driver and admits to consuming a moderate amount of alcohol before driving. In the ER, he complains of bilateral chest pain and left leg pain. His past medical history is significant for emphysema, diabetes mellitus and remote drug abuse. A traumatic fracture of the left femur is evident on physical examination. His initial arterial blood gas analysis shows a pH of 7.45, p02 of 81 mmHg and pC02 of 32 mmHg. His pulmonary capillary wedge pressure is 1OmmHg. After a 2000 ml IV fluid challenge, his p02 is 76 mmHg and his pulmonary capillary wedge pressure is 12 mmHg. Chest x-ray shows alveolar opacities over the right and left lower lobes. Hours after the accident, he complains of continued chest pain and shortness of breath. Which of the following diagnoses is most likely responsible for his shortness of breath?

A 23-year-old woman comes to the physician because of right-sided foot pain. The pain started 5 weeks ago and is sharp and localized to the forefoot. She recalls no trauma or other inciting event but is an avid runner training for a long-distance race. The pain has been worsening over the past 1 week and prevents her from doing her daily running activities. She takes no medications. She is a vegetarian and does not drink soda. She does not use tobacco, alcohol, or illicit drugs. She is not sexually active, and her last menstrual period was 8 weeks ago. Her temperature is 37°C (98.6°F), blood pressure is 100/60 mm Hg, pulse is 68/min, and respirations are 12/min. Her body mass index is 15 kg/m2. Examination reveals tenderness to palpation along the first four metatarsal bones on the dorsal surface of the right foot, normal range of motion, and no erythema or bruising. Which of the following is the most likely diagnosis?

An ultrasound is performed on a patient with right upper quadrant pain. It demonstrates a large gallstone in the cystic duct but also a polypoid mass in the fundus. Which of the following is an indication for cholecystectomy for a polypoid gallbladder lesion?

An alcoholic man has been suffering excruciating pain from chronic pancreatitis recalcitrant to analgesics and splanchnic block. A surgeon recommends total pancreatectomy. A patient who has a total pancreatectomy might be expected to develop which of the following complications?

A 36-year-old man who was hit by a car presents to the ER with hypotension. On examination, he has tenderness and bruising over his left lateral chest below the nipple. An ultrasound examination is performed and reveals free fluid in the abdomen. What is the most likely organ to have been injured in this patient?

A 30-year-old man is stabbed in the arm. There is no evidence of vascular injury, but he cannot flex his three radial digits. Which of the following structures has he most likely injured?

A 70-year-old man presents to the ER with several fractures and a ruptured spleen after falling 20 ft. Which of the following will occur in response to the injury?

A 62-year-old woman is seen after a 3-day history of fever, abdominal pain, nausea, and anorexia. She has not urinated for 24 hours. She has a history of previous abdominal surgery for inflammatory bowel disease. Her blood pressure is 85/64 mm Hg, and her pulse is 136. Her response to this physiologic state includes which of the following?

A newborn infant born from a mother with polyhydramnios presents with excessive salivation along with coughing and choking with the first oral feeding. An xray of the abdomen shows gas in stomach and a nasogastric tube coiled in the esophagus. Which of the following is the most likely diagnosis?

A 2-week-old infant presents with sudden onset of bilious emesis. Plain films of the abdomen show evidence of an intestinal obstruction. An upper gastrointestinal (UGI) contrast series reveals a midgut volvulus with the site of obstruction at the third portion of the duodenum. Which of the following is the most likely diagnosis?

A 65-year-old woman is involved in a motor vehicle collision and sustains multiple left-sided rib fractures. Upon presentation to the ER her vital signs are stable and she is in no respiratory distress. Chest x-ray reveals fractures of ribs 4 to 7 on the left side without evidence of hemothorax or pneumothorax. She is admitted for observation and a few hours later she develops shortness of breath. A repeat chest x-ray demonstrates a well-defined infiltrate in her left lung. What is the most likely diagnosis?

Following a head-on motor vehicle collision, a 21-year-old unrestrained passenger presents to the ER with dyspnea and respiratory distress. She is intubated and physical examination reveals subcutaneous emphysema and decreased breath sounds. Chest x-ray reveals cervical emphysema, pneumomediastinum, and a right-sided pneumothorax. What is the most likely diagnosis?

A 35-week-term infant presents with cyanosis shortly after birth. His arterial oxygen saturation is only 30%. Which of the following is the most likely diagnosis?

A 50-year-old patient presents with symptomatic nephrolithiasis. He reports that he underwent a jejunoileal bypass for morbid obesity when he was 39. Which of the following is a complication of jejunoileal bypass?

A 75-year-old man slips and falls at home, hitting his right chest wall against the kitchen counter. He has an area of exquisite pain to direct palpation over the seventh rib, at the level of the anterior axillary line. A chest x-ray film confirms the presence of a rib fracture, with no other abnormal findings. Which of the following is the most appropriate initial step in management?

A 71-year-old woman is brought to the physician by her distressed daughter. The daughter relates that, 3 days ago, her mother began to complain of right upper quadrant abdominal pain. She did not want to eat and "took to her bed sick." The daughter recalls that she complained of chills, nausea, and some vomiting. Physical examination reveals an obtunded, hypotensive, and obviously very sick elderly woman. She has impressive pain to deep palpation in the right upper quadrant, along with muscle guarding and rebound. Her temperature is 40C (104F), and laboratory analysis shows a white cell count of 22,000/mm3 with multiple immature forms, a bilirubin of 5 mg/dL and alkaline phosphatase of 840 U/L. The serum amylase is normal. An emergency sonogram shows multiple stones in the gallbladder, normal thickness of the gallbladder wall without pericholecystic fluid, dilated intrahepatic ducts, and common duct with a diameter of 2.1 cm. The sonographer cannot identify stones in the common duct. In addition to IV fluids and antibiotics, which of the following is the most appropriate next step in management?

A 54-year-old man, who 5 years ago underwent a laparotomy for a gunshot wound to the abdomen, is admitted to the hospital because of protracted vomiting and progressive abdominal distention. The symptoms began 5 days earlier, and since then he has not had a bowel movement or passed any gas. At the time of hospitalization, he has hyperactive bowel sounds and some abdominal discomfort, but does not have an acute abdomen. His abdominal x-ray films show dilated loops of small bowel, multiple air-fluid levels, and no free air under the diaphragms. He is placed on nasogastric suction and IV fluids. After 6 hours, he develops fever, leukocytosis, abdominal tenderness, and rebound tenderness, and his abdomen is silent. Which of the following is the most appropriate next step in management?

A 3-year-old boy is brought to the emergency room after spilling bleach onto his lower extremities. He is diagnosed with a chemical burn and all involved clothing are removed. In addition to resuscitation, which of the following is the most appropriate initial management of this patient?

Following a weekend of snowmobiling, a 42-year-old man comes to the emergency department with pain, numbness, and discoloration of his right forefoot. You diagnose frostbite. Which of the following is the proper initial treatment?

A 40-year-old woman complains of mild, intermittent pain and paresthesias in her right wrist. She reports the pain is worse at night and with driving. On physical examination hyperflexion of the right wrist reproduces the paresthesia. With regard to her diagnosis, which of the following is the most appropriate initial treatment?

A 19-year-old man receives un-cross-matched blood during resuscitation after a gunshot wound to the abdomen. He develops fever, tachycardia, and oliguria during the transfusion and is diagnosed as having a hemolytic reaction. Which of the following is the most appropriate next step in the management of this patient?

A 64-year-old man with history of severe emphysema is admitted for hematemesis. The bleeding ceases soon after admission, but the patient becomes confused and agitated. Arterial blood gases are as follows: pH 7.23; PO2 42 mm Hg; PCO2 75 mm Hg. Which of the following is the best initial therapy for this patient?

A 16-year-old adolescent boy with a history of severe hemophilia A is undergoing an elective inguinal hernia repair. Which of the following is the best option for preventing or treating a bleeding complication in the setting of this disease?

A 23-year-old woman undergoes total thyroidectomy for carcinoma of the thyroid gland. On the second postoperative day, she begins to complain of a tingling sensation in her hands. She appears quite anxious and later complains of muscle cramps. Which of the following is the most appropriate initial management strategy?

24-year-old firefighter sustains 30% total body surface area (TBSA) burns to his torso, face, and extremities. His wounds are treated topically with silver nitrate. Which of the following complications is associated with use of this agent?

A 22-year-old man sustains severe blunt trauma to the back. He notes that he cannot move his lower extremities. He is hypotensive and bradycardic. Which of the following is the best initial management of the patient?

A 14-year-old boy presents in the emergency department with very severe pain of sudden onset in his right testicle. There is no history of either trauma or recent mumps. He is afebrile, and a urinalysis shows no pyuria. The testis is swollen, exquisitely painful, high in the scrotum, and riding in a horizontal position. The cord above the testis is not tender. Which of the following is the most appropriate next step in management?

A 59-year-old man with a history of myocardial infarction 2 years ago undergoes an uneventful aortobifemoral bypass graft for aortoiliac occlusive disease. Six hours later he develops ST segment depression, and a 12-lead electrocardiogram (ECG) shows anterolateral ischemia. His hemodynamic parameters are as follows: systemic BP 70/40 mm Hg, pulse 100 beats per minute, CVP 18 mm Hg, PCWP 25 mm Hg, cardiac output 1.5 L/min, and systemic vascular resistance 1000 (dynes)/cm5. Which of the following is the single best pharmacologic intervention for this patient?

A 56-year-old man undergoes a left upper lobectomy. An epidural catheter is inserted for postoperative pain relief. Ninety minutes after the first dose of epidural morphine, the patient complains of itching and becomes increasingly somnolent. Blood-gas measurement reveals the following: pH 7.24, PaCO2 58, PaO2 100, and HCO3− 28. Which of the following is the most appropriate initial therapy for this patient?

A cirrhotic patient with abnormal coagulation studies due to hepatic synthetic dysfunction requires an urgent cholecystectomy. A transfusion of FFP is planned to minimize the risk of bleeding due to surgery. What is the optimal timing of this transfusion?

Ten days after an exploratory laparotomy and lysis of adhesions, a patient, who previously underwent a low anterior resection for rectal cancer followed by postoperative chemoradiation, is noted to have succus draining from the wound. She appears to have adequate source control—she is afebrile with a normal white blood count. The output from the fistula is approximately 150 cc per day. Which of the following factors is most likely to prevent closure of the enterocutaneous fistula?

A 45-year-old woman undergoes an uneventful laparoscopic cholecystectomy for which she receives 1 dose of cephalosporin. One week later, she returns to the emergency room with fever, nausea, and copious diarrhea and is suspected of having pseudomembranous colitis. She is afebrile and has no peritoneal signs on abdominal examination. She has a mild leukocytosis with a left shift. Which of the following is the appropriate initial management strategy?

An 18-year-old woman develops urticaria and wheezing after an injection of intravenous contrast for an abdominal CT scan. Her blood pressure is 120/60 mm Hg, heart rate is 155 beats per minute and respiratory rate is 30 breaths per minute. Which of the following is the most appropriate immediate therapy?

A patient involved in a high-speed automobile collision arrives in the emergency department unconscious, with multiple facial fractures; brisk bleeding into his nose, mouth, and throat; and gurgly, irregular, noisy breathing. Which of the following would be the best method to secure an airway in this patient?

A 22-year-old woman is involved in a major motor vehicle accident and receives a tracheostomy during her hospitalization. Five days after placement of the tracheostomy she has some minor bleeding around the tracheostomy site. Which of the following is the most appropriate immediate therapy?

A 33-year-old woman is brought to the emergency room from the scene of a severe motor vehicle accident. She is combative, confused, uncooperative, and appear dusky and dyspneic. Which of the following is the most appropriate management of her airway?

A 42-year-old man who was in a house fire is transferred to your burn unit. He has singed nose hairs and facial burns. Direct laryngoscopy in the emergency room demonstrates pharyngeal edema and mucosal sloughing. He has 60% total body surface area burns. Which of the following is the next step in the management of this patient?

A 24-year-old man presents in septic shock from an empyema. He is febrile to 103°F, tachycardic in the 120s, and hypotensive to the 90s. His oxygen saturation is 98% on 2-L oxygen. His white blood cell count is 25,000/mL and creatinine is 0.8 mg/dL. His blood pressure does not respond to fluid administration despite a CVP of 15. Which of the following therapies is indicated in managing this patient?

Shortly after the administration of an inhalational anesthetic and succinylcholine for intubation prior to an elective inguinal hernia repair in a 10-year-old boy, he becomes markedly febrile, displays a tachycardia of 160, and his urine changes color to a dark red. Which of the following is the most appropriate treatment at this time?

A 37-year-old woman is brought to the surgical floor after undergoing a routine vaginal hysterectomy that morning. She had been fasting since midnight the night prior to her surgery. She has no past medical history except for uterine fibroids and takes only oral contraceptive pills regularly. During the procedure, she was reported to lose approximately 300 mL of blood. On the floor, she appears well but complains of some fatigue. Her blood pressure is 110/60 mm Hg, and her pulse is 100/min. She is not taking food or water yet because of persistent nausea and vomiting postoperatively. Which of the following is the most appropriate next step in management?

A 22-year-old woman is brought to the emergency department after a motorcycle accident in which she sustained severe crush injuries of her lower extremities. In the field, her Glasgow Coma Score was 14. She is awake and alert on arrival after having been given morphine for pain control. Any details of her past medical history are unknown. Initial examination shows a blood pressure of 140/80 mm Hg and pulse of 100/min. Her oxygen saturation on room air is 95% by pulse oximeter. An ECG is obtained and shows very large, peaked T-waves in leads V1-V6. Which of the following is the most appropriate initial step in patient care?

A 32-year-old man undergoes a distal pancreatectomy, splenectomy, and partial colectomy for a gunshot wound to the left upper quadrant of the abdomen. One week later he develops a shaking chill in conjunction with a temperature spike of 39.4°C (103°F). His blood pressure is 70/40 mm Hg, pulse is 140 beats per minute and respiratory rate is 45 breaths per minute. He is transferred to the intensive care unit (ICU), where he is intubated and a Swan-Ganz catheter is placed. Which of the following is consistent with the expected initial Swan-Ganz catheter readings?

A 72-year-old man has multiple injuries and an altered sensorium after a high-speed motor vehicle collision. He is intubated for his decreased mental status. During intubation, a large amount of gastric contents are noted in the posterior pharynx and he aspirates. Which of the following is the appropriate initial treatment?

50-year-old woman with a history of essential hypertension presents to the emergency department with sudden onset of a severe headache, nausea and vomiting, and photophobia. On examination, her BP is 160/100 mmHg. She is mildly confused and has nuchal rigidity, without focal neurologic signs. Once the diagnosis has been confirmed, Rupture cerebral aneurysm, which of the following is the next most important step in patient management?

A 22-year-old gang member arrives in the emergency department with multiple gunshot wounds to the chest and abdomen. He has labored breathing and is cyanotic, diaphoretic, cold, and shivering. He is wide awake, and in a normal tone of voice he tells everyone that he is going to die. An initial survey reveals a blood pressure of 60/40 mm Hg. His pulse is 150/min and barely perceptible. He is in obvious respiratory distress and has big distended veins in his neck and forehead. His trachea is deviated to the left, and the right side of his chest is hyperresonant to percussion, with no breath sounds. Which of the following is the most appropriate initial step in management?

On the 5th postoperative day after abdominal surgery, a patient has been draining copious amounts of clear pink fluid from his midline laparotomy wound. A medical student removes the dressing, confirms that it is soaked, and sees a normal-appearing fresh wound with a row of skin staples in place. The student asks the patient to sit up so he can get out of bed and be helped to the treatment room for a more thorough examination. When the patient complies, the wound opens widely, and a handful of small bowel suddenly rushes out. Which of the following is the most appropriate management at this time?

Several days following esophagectomy, a patient complains of dyspnea and chest tightness. A large pleural effusion is noted on chest radiograph, and thoracentesis yields milky fluid consistent with chyle. Which of the following is the most appropriate initial management of this patient?

A 16-year-old girl with a history of ulcerative colitis managed with steroid therapy presents to the emergency department with a 36-hour history of nausea, crampy abdominal pain, and severe bloody diarrhea. On examination, the patient is febrile and pale, with a blood pressure of 90/60 mmHg and heart rate of 130 beats/min. Her abdomen is distended and diffusely tender. A complete blood count (CBC) demonstrates a leukocytosis with a left shift. The patient receives IV fluid resuscitation and nasogastric (NG) tube decompression. Further therapeutic interventions should include which one of the following?

A severely traumatized woman is seen in the emergency room (ER) with decreased mental status. Prior to intubation, she does not open her eyes, withdraws with all of her extremities, and makes incomprehensible sounds. What is her Glasgow coma scale score?

A 25-year-old woman was involved in a motor vehicle crash and sustained a significant closed-head injury, a pulmonary contusion, and a pelvic fracture. She is unresponsive and is ventilated in the intensive care unit (ICU). Which of the following is the best initial approach to the management of this patient’s nutritional needs?

A young mother is at the pediatrician's office for a routine well-baby visit for her 18-month-old son. It is immediately noticed that one of the baby's pupils is white, while the other one is black. When asked about it, the mother relates that she saw that curious situation for the first time 1 week ago, but since the baby was otherwise asymptomatic, she did not think it merited special attention. Which of the following is the most appropriate course of action?

A 70-year-old man is admitted to the ICU after repair of an abdominal aortic aneurysm. He has a prior history of hypertension and mild congestive heart failure, which were adequately controlled with digoxin and diuretics. To facilitate perioperative management, a Swan-Ganz (multilumen pulmonary artery) catheter was inserted in the operating room. During the first few hours postoperatively, the patient is noted to have a blood pressure of 140/70 mmHg, heart rate of 110/min, flat neck veins, a pulmonary arterial wedge pressure of 9 mmHg, and poor urine output. Which of the following is the most appropriate next step in management of this patient?

The left ureter is partially transected (50% of circumference) during the course of a difficult operation on an unstable, critically ill patient. Which of the following would be the most appropriate management of this injury given the patient’s unstable condition?

A 65-year-old man presents to the emergency department with an abrupt onset of excruciating chest pain 1 hour ago. The pain is localized to the anterior chest, but radiates to the back and neck. On examination, the patient is afebrile, with a BP of 210/110 mmHg, pulse rate of 95/min, and a respiratory rate of 12/min. He appears pale and sweaty. Unequal carotid, radial, and femoral pulses are noted. An electrocardiogram (ECG) shows nonspecific ST-T segment changes. Chest x-ray shows a slightly widened mediastinum and normal lung field. Which of the following is the first step in management of this patient?

A 26-year-old previously healthy man was pinned under a crane at a construction site. After a prolonged extrication, he was brought to the emergency department, immobilized on a back board and receiving 100% oxygen by mask. He is alert and complaining of chest pain with respiratory effort. On examination, he is found to have an oxygen saturation of 90% by pulse oximetry, shallow respirations at a respiratory rate of 35/min, heart rate of 120 beats/min, and a blood pressure of 85/60 mmHg. The trachea is deviated to the right. There is tenderness and crepitation over the left chest wall, asymmetric chest wall movement, and decreased air entry over the left lung field. Which of the following is the most appropriate next step in the initial evaluation and management of this patient?

A 13-year-old boy is brought to the emergency department at midnight with a 4-hour history of right scrotal pain that was sudden in onset and associated with nausea and one episode of vomiting. On examination, he is in obvious distress. He has mild right lower abdominal tenderness, and high-riding, tender right testes. CBC and urinalysis are normal. Which of the following is the most appropriate next step in management?

A 75-year-old man is brought to the emergency department for severe pain in the left flank and back of 1 hour duration. He has a prior history of a myocardial infarction and coronary artery bypass grafting 8 years ago. On examination, he is found to have a BP of 80/50 mmHg, pulse rate of 110/min, respiratory rate of 15/min, and a pulsatile, tenderabdominal mass. He has had two large-bore IV lines placed by the paramedics. He is alert and oriented, and gives consent for surgery. Which of the following is the most appropriate next step in management of this patient?

A 14-year-old boy dives into the shallow end of a swimming pool and hits his head against the bottom. When he is rescued, he shows a complete lack of neurologic function below the neck. He is still breathing on his own, but he cannot move or feel his arms and legs. The paramedics carefully immobilize his neck for transportation to the hospital, and they alert the emergency department to his impending arrival. Once there, which of the following would most likely have an immediate benefit for this patient?

A 61-year-old man comes in because of colicky abdominal pain and vomiting of 3 days' duration. On physical examination, he is moderately distended and has high pitched hyperactive bowel sounds and a 5-cm tender groin mass. On direct questioning, he explains that he has had that bulge for many years, but has always been able to "push it back in" when he lies down. For the past 3 days, however, he has been unable to do so. He has a temperature of 38.9C (102F) and a white blood cell count of 12,500/mm3. Which of the following is the most appropriate management at this time?

In a rollover car accident, a 42-year-old woman is thrown from the car. The car subsequently lands on her and crushes her. On physical examination in the emergency department, it is determined that she has a pelvic fracture, which is confirmed by portable x-rays done as she is being resuscitated. Her initial blood pressure is 50/30 mm Hg, and her pulse is 160/min and barely perceptible. Thirty minutes later, after 2 L Ringer's lactate and 2 U packed cells have been infused, her pressure is only 70/50 mm Hg, and her pulse is 130/min. A sonogram done in the emergency department shows no intra-abdominal bleeding, and a diagnostic peritoneal lavage confirms that there is no blood in the abdomen (the recovered fluid is pink, but not grossly bloody). Rectal and vaginal exams show no injuries to those organs. There is no blood in her urine. Which of the following is the most appropriate next step in management?

A 34-year-old man is brought to the emergency department after being rescued from a burning building. His temperature is 36.90C (98.60 F), blood pressure is 90/60 mm Hg, pulse is 100/min and respirations are 28/min. Examination shows second and third degree burns over 15% of his body. His oropharynx shows erythema and scattered blisters. His lungs are clear to auscultation and his abdomen is soft and nondistended. His blood carboxyhemoglobin concentration is 20%. Which of the following is the best management for this patient?

A 28-year-old man is brought to the emergency department 4 hours after being involved in a motor vehicle collision. His blood pressure is 90/50 mm Hg, pulse is 120/min and respirations are 30/min. Examination shows a stuporous man with bruises over his extremities and upper abdomen. His trachea is midline and his neck veins are flat. His abdomen is moderately distended but non-tender. Immediately after being intubated and placed on mechanical ventilation he goes into cardiac arrest. Which of the following could have prevented cardiac arrest in this patient?

A 28-year-old male is brought to the emergency department after being an unrestrained passenger in a motor vehicle collision. In the ambulance on his way to the hospital, he receives 2 liters of normal saline intravenously and 5 Umin of oxygen by nasal cannula. On physical examination, his blood pressure is 100/70 mmHg, heart rate is 120/min, and respiratory rate is 40/min. He is agitated and moves all four extremities spontaneously. His pupils are symmetric and reactive to light. His neck veins are distended, and his trachea is deviated to the right. Which of the following is the best initial management for this patient?

A 62-year-old man presents to the emergency department (ED) with one hour of severe epigastric pain. He has been having some epigastric pain exacerbated by eating for the last several days. He feels nauseous, and has vomited once since the pain began. His past medical history is significant for hypertension, diabetes, hyperlipidemia, and coronary artery disease. He underwent coronary bypass surgery one year back. His current medications are simvastatin, aspirin, clopidogrel, metoprolol, enalapril and metformin. His blood pressure is 140/ 100 mmHg, and heart rate is 65/min. His ECG is normal. Chest x-ray findings are shown on the slide below. Which of the following is the best step in the management of this patient?

A 23-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He has multiple organ injuries and is listed in critical condition. Physical examination shows an open wound in the right lower extremity and significant blood loss. He is in hypovolemic shock. Which of the following is the first parameter to change in hypovolemic shock?

A 25-year-old man is brought to the emergency department after falling 12m (40ft) from a ladder. He is unconscious. Examination shows obvious head and neck injuries, and a fractured forearm. He is totally apneic. Which of the following would be the best method to establish an immediate definitive airway in this patient?

35-year-old previously healthy male comes to the emergency department because of a 4-hour history of severe abdominal pain. The pain had initially started in the periumbilical area but has now shifted to the right lower quadrant. He also felt nauseated and vomited twice. He has had no previous surgeries. His temperature is 38.9C (102F), blood pressure is 125/80 mm Hg, pulse is 100/min and respirations are 20/min. Examination shows tenderness in the right lower quadrant. Palpation of the left lower quadrant produces pain in the right lower quadrant. Urinalysis is negative. Which of the following is the most appropriate next step in management?

22-year-old man involved in a motor vehicle collision undergoes a prolonged operation to repair a left femur fracture and femoral artery injury. During the first night after surgery he has pain in the left leg. Despite adequate narcotics, his pain is unremitting; the pain is worse with passive leg movement. Examination shows a pale and swollen leg that is tender to the touch; pulses are palpable. Which of the following is the most appropriate next step in management?

A 27-year-old man sustains a single gunshot wound to the left thigh. In the ER, he is noted to have a large hematoma of his medial thigh. He complains of paresthesias in his left foot. On examination, there are weak pulses palpable distal to the injury and the patient is unable to move his foot. Which of the following is the most appropriate initial management of this patient?

A 25-year-old woman arrives in the ER following an automobile accident. She is acutely dyspneic with a respiratory rate of 60 breaths per minute. Breath sounds are markedly diminished on the right side. Which of the following is the best first step in the management of this patient?

A 75-year-old man with a history of coronary artery disease, hypertension, and diabetes mellitus undergoes a right hemicolectomy for colon cancer. On the second postoperative day, he complains of shortness of breath and chest pain. He becomes hypotensive with depressed mental status and is immediately transferred to the intensive care unit. After intubation and placement on mechanical ventilation, an echocardiogram confirms cardiogenic shock. A central venous catheter is placed that demonstrates a central venous pressure of 18 mm Hg. Which of the following is the most appropriate initial management strategy?

A 27-year-old man presents to the ER after a high-speed motor vehicle collision with chest pain and marked respiratory distress. On physical examination, he is hypotensive with distended neck veins and absence of breath sounds in the left chest. Which of the following is the proper initial treatment?

A 20-year-old man presents after being punched in the right eye and assaulted to the head. On a facial CT scan, he is noted to have a blowout fracture of the right orbital floor. Which of the following findings mandates immediate surgical intervention?

A 33-year-old woman is seen in the ER with severe rectal bleeding. She has a history of ulcerative colitis. Her blood pressure is 78/56 mm Hg, her pulse is 144, and she is pale and clammy. Which of the following responses is likely to occur after administration of Ringer lactate solution?

A 4-week-old male infant presents with projectile, nonbilious emesis. Ultrasound of the abdomen reveals a pyloric muscle thickness of 8 mm (normal 3-4 mm). Which of the following is the best initial management of this patient?

A 1-month-old female infant presents with persistent jaundice. A serum direct bilirubin is 4.0 mg/dL and an ultrasound of the abdomen shows a shrunken gallbladder and inability to visualize the extrahepatic bile ducts. Which of the following is the most appropriate initial management of this patient?

A 10-year-old girl is the unrestrained backseat passenger in a high-speed motor vehicle collision. She is intubated in the field for unresponsiveness and on presentation to the ER, her heart rate is 160 beats per minute, and her blood pressure is 60/35 mm Hg. She weighs 30 kg. Which of the following is the most appropriate recommendation for her fluid resuscitation?

A 21-year-old woman sustains a stab wound to the middle of the chest. Upon arrival to the ER she has equal breath sounds, blood pressure of 85/46 mm Hg, distended neck veins, and pulsus paradoxus. Which of the following is the most appropriate management of this patient?

A 58-year-old man presents to the ER after falling 10 ft from a ladder. Examination reveals stablevital signs, no evidence of respiratory distress, and multiple right-sided rib fractures. Chest x-ray shows a hemothorax on the right side and a right tube thoracostomy is performed in the ER. Approximately 700 mL of blood is immediately drained with placement of the thoracostomy tube. Over the next 4 hours he continues to drain 300 mL/h after the original evacuation. Which of the following is the definitive treatment for this patient?

A 25-year-old man is brought to the emergency department by ambulance after falling from a ladderfor 12 m (40 ft). He was placed on a backboard for spinal stabilization. Intravenous access was obtained en route, and infusion of crystalloids was initiated. The patient is comatose on arrival to the emergency department. Examination shows facial lacerations, a depressed skull fracture, and a forearm fracture. In the emergency department, his blood pressure is 92/45 mm Hg, pulse is 127/min, and respirations are 6/min. His pulse oximetry shows 86% on 40% facemask oxygen. Which of the following is the most appropriate next step in management?

A 42-year-old man is found unconscious at the scene of a motor vehicle collision. He is rushed to the emergency department, where his blood pressure is found to be 70/40 mm Hg and his respirations are 32/min. On physical examination, his trachea is deviated to the left and his breath sounds are decreased on the right side. His neck veins are distended bilaterally. The abdomen is soft and non-distended. There is significant swelling of the right thigh. Which of the following is the most appropriate next step in the management of this patient?

A 54-year-old man is brought to the emergency department 10 minutes after being involved in a motor vehicle accident. He was an unrestrained driver and hit a car while speeding on the highway. On arrival to the emergency department, he is spontaneously breathing and noncyanotic. His temperature is 37°C (98.6°F), blood pressure is 104/50 mm Hg, pulse is 122/min, and respirations are 16/min. Examination shows facial lacerations and multiple ecchymoses on the anterior chest and abdomen. He appears obtunded. Which of the following is a component of the Glasgow coma scale (GCS) assessment for this patient?

A 22-year-old man is stabbed in the right chest with a 5-cm-long knife blade. On arrival at the emergency department, he is wide awake and alert. He is speaking with a normal tone of voice but complaining of shortness of breath. The right hemithorax is hyperresonant to percussion and has no breath sounds; the rest of the initial survey is negative. His blood pressure is 110/75 mm Hg, pulse is 86/min, and venous pressure is 3cm H2O. Pulse oximetry shows a saturation of 85%. Which of the following is the most appropriate next step in patient care?

A one-year-old boy is brought to the emergency department with scalds on both the buttocks and thighs. His mother states that the child was burned because she accidentally drew a bath for the child with water that was too hot. She states the injury occurred 2 days ago. On examination, the child is irritable. Second-degree burns are noted on the buttocks, genitalia, waist, proximal thighs and feet. There is an abrupt demarcation between the burned and unaffected skin. A faint yellow patch of discoloration is noted on the left thorax with a slight violaceous hue. The child has not yet had his 1-year vaccinations. Which of the following is the most appropriate next step in management?

A 47-year old woman comes to the clinic because of worsening left breast swelling and pain. She had mastitis when she nursed her first child 20 years ago. She has not seen a doctor since that time. She is afebrile. Breast examination shows the left breast is enlarged with a 7 x 6 cm area of edema and erythema. A poorly localized mass without fluctuation is palpated in that area. Scant non-bloody discharge is noted on the nipple, and several large axillary nodes are palpated. Which of the following is the most appropriate next step in management?

A man involved in a high-speed, head-on automobile collision arrives at the emergency department in a deep coma. His pupils react poorly to light but are of equal size. An airway is placed, and the patient is sent for CT scan of the head with extension to the neck. The study shows no cervical spine fractures, but does reveal a small, crescent-shaped hematoma on the right side, with no deviation of the midline structures. Which of the following is the most appropriate next step in management?

A 19-year-oldgangmemberisshotintheabdomenwith a .38 caliber revolver. The entry wound is in the epigastrium, to the left of the midline. The bullet is lodged in the psoas muscle on the right. He is hemodynamically stable, and the abdomen is moderately tender. Which of the following is the most appropriate next step in diagnosis?

Five days after an uneventful cholecystectomy, an asymptomatic middle-aged woman is found to have a serum sodium level of 125 mEq/L. Which of the following is the most appropriate management strategy for this patient?

A 33-year-old woman is undergoing a diagnostic work-up because she appears to have Cushing syndrome. She has elevated levels of cortisol, which are not suppressed when she is given high-dose dexamethasone. ACTH levels are greater than 200 pg/ mL. A chest x-ray film shows a central, 3-cm round mass on the hilum of the right lung. Bronchoscopy and biopsies confirm a diagnosis of small cell carcinoma of the lung. Which of the following is the preferred treatment for this woman?

A multiple trauma patient receives 14 units of packed red cells and several liters of Ringer's lactate solution during a laparotomy for multiple intra-abdominal injuries. The surgeons note that blood is oozing from all dissected raw surfaces, as well as from his TV line sites. His core temperature is normal. Which of the following is the most appropriate next step in management?

A patient with a nonobstructing carcinoma of the sigmoid colon is being prepared for elective resection. Which of the following reduces the risk of postoperative infectious complications?

A young man is shot with a .45 caliber revolver, point blank in the lower abdomen, just above the pubis. The entrance wound is at the midline, and there is no exit wound. X-ray films show the bullet embedded in the sacral promontory, to the right of the midline. Digital rectal examination and proctoscopic examination are negative, but he has gross hematuria. He is hemodynamically stable. Which of the following is the most appropriate next step in management?

A 25-year-old man is shot with a .22 caliber revolver. The entrance wound is in the anteromedial aspect of his upper thigh, and the exit wound is about 3 inches lower, in the posterolateral aspect of the thigh. He has a large, expanding hematoma in the upper inner thigh. There are no palpable pulses in the foot. The bone is intact by physical examination and x-ray films. Which of the following is the most appropriate next step in management?

A 44-year-old woman is recovering from a mild episode of acute ascending cholangitis secondary to choledocholithiasis. When seen initially, she had a spiking fever, leukocytosis, and a very high alkaline phosphatase; however, all these findings subsided rapidly after she was placed on IV antibiotics. A sonogram of the right upper quadrant on the day of admission showed the presence of gallstones in the gallbladder, but the diameter of the biliary ducts was normal. It was assumed that she had passed a common duct stone, and plans to do an endoscopic retrograde cholangiopancreatogram (ERCP) were canceled. While awaiting elective cholecystectomy, she again developed a fever and leukocytosis, and her liver function tests showed minimal elevation of her bilirubin (to 2.5 mg/dL) and alkaline phosphatase (to 115 U/L). A repeat sonogram shows no changes in her biliary ducts, but now there is a 6-cm abscess in the right lobe of the liver. Which of the following is the most appropriate treatment for this new development?